Remote Value-Based Specialist

The VBC Specialist is responsible for providing education, counseling, advocacy, and coordination of services to patients belonging to customers using the eClinicalWorks & healow product suite. The VBC Specialist will act as an extension of the patient’s Care Giver or Primary Care Provider (PCP) in helping to close the gaps in patient’s care. This individual will build rapport with patients through one or two virtual sessions each month supporting them through services such as Chronic Care Management (CCM), Behavioral Health Integration (BHI), Principal Care Management (PCM) and Remote Patient Monitoring (RPM). Furthermore, the VBC Specialist will empower patients to meet their goals, guide them in their healthcare journey, advocate for their needs by utilizing active listening skills, investigating patient concerns, documenting appropriately, and communicating professionally with the patient’s care. The VBC Specialist will collaborate directly with multiple primary care office-based health care teams to provide patient-centered care and frequent follow-up with Patients and Providers.

RESPONSIBILTIES

Directly interfaces with patients using technology, telephone, email and text messaging to support patient self-management and support for the various chronic disease management programs (CCM, RPM, etc.).
Provides education, coordination and support to patients on the follow-up and management of their chronic illness.
Contributes to monthly, quarterly and annual reporting as required for eClinicalWorks / healow and for program certification.
Utilizes care management plans, interventions, treatment goals and other products / features within the eClinicalWorks & healow product suite for patient-specific documentation.
Adheres to and ensures compliance with CMS standards on chronic care management and follow-up.
Works with the respective Team Lead, primary care providers, care center staff, and nurse managers to:
Collaborate with patients and families to provide high quality patient assessments.
Use motivational interviewing techniques to assist patients with adhering to self-management goals and action plans with timeframes.
Ensure timely implementation of assessments, care plans and appropriate interventions for identified patient populations to determine health, social situation, physical environment, mental health, substance abuse, economic status and educational needs of patients.
Leverage the eClinicalWorks & healow product platforms to identify chronically ill patients and opportunities.
Identify utilize cultural and community resources to assist patients, and to maintain an accurate database of services and contact information of such resources.
Arrange contact with other resources needed to support patient treatment plans.
Utilize evidence-based educational offerings and care plans for chronic diseases such as diabetes, obesity, hypertension, asthma, depression and COPD.
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